Donor Information
First Name
Last Name
Billing Address:
City:
State:
Zip:
Phone Number:
Email Address:
Donation Amount
I would like to make a donation in the amount of:
$1000
$500
$250
$120
$60
$35
Other Amount:
Please display my name on the participant's public donor wall as:
Please do not display my name on the donor wall.
Participant Information
Event Name2025 Syracuse Heart Walk
Event ID11470
Participant ID29851976
Participant NameBenjamin Peet
Team NamePM&R Rehab
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Syracuse Heart Walk | Four Gateway Center444 Liberty Ave, Ste 1300 | Pittsburgh, PA 15222